Proposal for future diagnosis and management of vascular tumors by using automatic software for image processing and statistic prediction.

RATIONALE
Infantile Hemangiomas (IH) are the most frequent tumors of vascular origin, and the differential diagnosis from vascular malformations is difficult to establish. Specific types of IH due to the location, dimensions and fast evolution, can determine important functional and esthetic sequels. To avoid these unfortunate consequences it is necessary to establish the exact appropriate moment to begin the treatment and decide which the most adequate therapeutic procedure is.


OBJECTIVE
Based on clinical data collected by a serial clinical observations correlated with imaging data, and processed by a computer-aided diagnosis system (CAD), the study intended to develop a treatment algorithm to accurately predict the best final results, from the esthetical and functional point of view, for a certain type of lesion.


METHODS AND RESULTS
The preliminary database was composed of 75 patients divided into 4 groups according to the treatment management they received: medical therapy, sclerotherapy, surgical excision and no treatment. The serial clinical observation was performed each month and all the data was processed by using CAD.


DISCUSSIONS
The project goal was to create a software that incorporated advanced methods to accurately measure the specific IH lesions, integrated medical information, statistical methods and computational methods to correlate this information with that obtained from the processing of images. Based on these correlations, a prediction mechanism of the evolution of hemangioma, which helped determine the best method of therapeutic intervention to minimize further complications, was established.


Introduction
The spectrum of vascular anomalies includes two distinct entities: malformations and vascular tumors. Vascular tumors are represented by infantile hemangiomas (IH), the most frequent type of benign tumor in children and other types of hemangiomas (hemangioendothelioma). IH are benign vascular tumors characterized by the proliferation of endothelial cells and which, during the stages of development, present an increase of the number of sanguine vessels starting from the periphery towards the center of the formation. Because of this vascular development, the dimension and the texture of the tumor are constantly changing, making it difficult to diagnose and to elect the therapeutic methods [1].
The majority of vascular tumors appear in the first weeks of life; only 30% are present at the moment of birth. The incidence in newborn is of 1, 1 -2, 6% and significantly increases up to 12% in the first year of life [2]. IH are more frequently met in feminine sex and have an increased incidence with premature infants (30% frequency). In terms of localization, 56% are at the head and neck level, 23% at the body level, 19% affecting extremities and 2% in the genital area [3].
Until present, the therapeutical options have been multiple and have varied significantly in connection with the equipment of the treatment center and the experience of the physician. Due to the fact that the majority of IH do not present complications during the course of evolution and involute spontaneously, a treatment by intervention is not usually indicated. One can relate to therapeutical methods in case of hemangiomas that present complications (ulcerations, bleedings), for  The loca htly different f er cases affec e involving t %) (Fig. 4).
We were tographic, ultr anamnestic mination and s continued ng at least 5 period was of all the measu g the same de Among t most importan digital images urred especia ntioned once   infants and small children, who had a diminished capacity of complying with the logistic requirements for the recordings. The agitation of the patient during the clinical examination and the imagistic investigation led to unclear photos, inadequate video recordings and inexact ultrasound recordings. As a measure of diminishing this impediment, a close co-operation with the family of the patients was required, together with a permanent exchange of information. The challenge was solved by centralizing a sufficient number of medical cases and associated images. The number of images collected for each studied period was sufficiently high in order to choose the most relevant data that were sent for processing.
The clinical documentation was the input data set that was taken by the engineering and mathematical researchers, which worked together on two successive levels: on one hand, the information extracted from the images was be processed, on the other hand, the results of this processing were correlated (i.e. put into a mathematical correlation) with the clinical observations. The result of this correlation allowed the obtaining of a prediction method that was made available to the medical side, so that with new information from imaging (and of course by using the developed software) the most likely evolution was anticipated. The clinical results subsequently obtained showed the attained level of accuracy of the developed prediction method and, either were a confirmation of it, or generated an additional step in refining the method.

Discussions
At present, the pathology benefits of very little study in our country and there is no well-defined protocol to supervise in time or to treat this affection.
Until the beginning of the '80s, the classification described both the vascular tumors and the malformations as "vascular birth signs" [4]. In 1982, the first classification of the vascular anomalies was established by separating them into hemangiomas (vascular tumors) and malformations. The key factor of this separation was the identification of an accentuated proliferation phase of the vascular tumors followed by an involution phase. In 2012, a new classification was proposed, taking into consideration the clinical aspect and the degree of tissue damage: localized hemangiomas, segmented hemangiomas, undetermined and multifocal hemangiomas [5].
The project proposal was based upon the development of advance methods for the precise and objective measuring of specific lesions of infantile hemangiomas and upon the prediction of the evolution of the hemangiomas in order to determine the best therapeutical solution. The natural evolution of IH was unique and presented 5 stages of development, as described in Table 1. The clinical characteristics of each stage were co-related with the data registered with the help of a Doppler ultrasound (CCDS) which codified the colors [2]. Besides the growth speed of the IH, their localization was the most important criteria that had to be followed as a therapeutical attitude. The therapy generated systemic or local adverse reactions, especially in the presence of disfigurative scars. Because of this reason, the interventional treatment was limited in case of IH that determined important functional or esthetical complications. Out of the group of problematic IH which necessitated treatment, the following could be identified: the hemangiomas of the facial area (periorbital, perioral, ears area, lips area or nose area), the anal and genital area (vulva, urethra, anus), and the ones which had an accelerated, diffuse and infiltrative proliferation, independently of the affected region [2].
Due to the possibility of the IH of spontaneously regressing, waiting and watching remained viable therepeutical methods, in the case of lesions small and without complications localized in non-problematic areas of the body. IH of the head and neck area were the most frequent and were also the most disfigurative because of the affected areas (Fig. 5 a,b), as well as the hemangiomas with an important dimension, both in length and in depth. These made the taking of a rapid decision regarding the best therapeutical method, imperative.

Conclusions
The results of the study implied real health benefits for both patients and the health system, receiving a minimization of costs per patient in this condition. By decreasing the number of procedures and defining a single therapeutic strategy for the treatment of a patient, amounts could be saved and consequently allocated for the benefit of other needs. Moreover, if the aesthetic and functional result is maximized, the resources allocated for the patient's reintegration into society will be saved, which is more costly if the degree of failure is higher. Decreasing the disease follow up period, speeding the diagnosis, diminishing the hospitalization time, a faster social integration of the patients, are only a few benefits that such a study brings, not only for the patients, but also for the national and European medical system.